The CMS RAC attacks are at the door and so is the National Practitioners Data Bank; Fmr. Assistant United States Attorney-Senior Attorney OIG-HHS Kenneth Haber advises all healthcare providers and facilities

Home » Articles » The CMS RAC attacks are at the door and so is the National Practitioners Data Bank; Fmr. Assistant United States Attorney-Senior Attorney OIG-HHS Kenneth Haber advises all healthcare providers and facilities

CMS has already initiated its bounty hunter system as to physicians and facilities for recovery of expended funds. That means that the targeted provider must repay the challenged payments which are predicated upon the self-serving assertions of the CMS Recovery Audit Contractors [RAC] or expend the funds to challenge the claim through the administrative appeal system. RACs receive a percentage of the recovery as their compensation. At the Administrative Appeals Council [MAC]/the Administrative Law Judge [ALJ] level, the RAC does not even have to expend the cost of appearing. The CMS ALJ will appoint an expert to report on the validity of the RAC’s claim against the provider. All the RAC has to do is to throw mud at you and you have to prove that you are clean. Below is a CMS press release concerning the RACs. Bear in mind, that this is several years old but is being provided due to its importance to all providers. Prepare for and possibly avoid a RAC attack by establishing a Compliance Program. A Compliance Program is required under the new Healthcare Reform Act for all providers under Medicare.

Kenneth Haber is a former Assistant U.S. Attorney for the Department of Justice and a former Senior Attorney in the office of the Inspector General of the Department of Health and Human Services for a total of over 12 years. As a private healthcare law practitioner since 1984, Ken brings with him a deep understanding of both the need for compliance with regulatory and statutory standards in our healthcare programs and the realities of running a healthcare business.

CMS: Announces

Background

The Centers for Medicare & Medicaid Services (CMS) has taken the next steps in the agency’s comprehensive efforts to identify improper Medicare payments and fight fraud, waste and abuse in the Medicare program by awarding contracts to four permanent Recovery Audit Contractors (RACs) designed to guard the Medicare Trust Fund.

In the Tax Relief and Health Care Act of 2006, Congress required a permanent and national RAC program to be in place by January 1, 2010. The national RAC program is the outgrowth of a successful demonstration program that used RACs to identify Medicare overpayments and underpayments to health care providers and suppliers in California , Florida , New York , Massachusetts , South Carolina and Arizona . The demonstration resulted in over $900 million in overpayments being returned to the Medicare Trust Fund between 2005 and 2008 and nearly $38 million in underpayments returned to health care providers.

The goal of the recovery audit program is to identify improper payments made on claims of health care services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments. Overpayments can occur when health care providers submit claims that do not meet Medicare’s coding or medical necessity policies. Underpayments can occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed. Health care providers that might be reviewed include hospitals, physician practices, nursing homes, home health agencies, durable medical equipment suppliers and any other provider or supplier that bills Medicare Parts A and B.

The new RACs were selected under a full and open competition. The RACs will be paid on a contingency fee basis on both the overpayments and underpayments they find. The selection of the new contractors was based on a best value determination for the Federal government that included a sound technical approach for the level and quality of claim analysis and detail to exceptional customer service, conflict of interest reviews and lowest contingency fee.

Provider Education Activities

As part of preparing Medicare providers for the RAC program as it is phased in nationally,

CMS will continue working closely with national and state medical, hospital and nursing home associations to strengthen relationships to be more proactive and anticipate the needs and concerns of health care providers. Before work begins, the RACs will hold Town Hall type meetings in each state with health care providers and CMS staff and representatives from the RACs in October and November.

CMS is also using lessons learned from the RAC demonstration to make improvements in the permanent RAC program. For example, the program will be more transparent by listing the types of issues undergoing review on each of the RACs’ Web sites. Each RAC will also employ a full-time medical director to help in the review of claims.

Soon after outreach efforts are made this month and in November, some health care providers in the states that are part of the first phase may begin to receive either requests for medical records or a letter requesting that an overpayment be repaid for their claims that were submitted to and paid for by Medicare. To prepare for the start of the program, health care providers should consider conducting an internal assessment to ensure that submitted claims meet the Medicare rules. Other steps that providers should take include:

Identifying where improper payments have been persistent by reviewing the RACs’ Web-sites and identifying any patterns of denied claims within their own practice or facility.
Implementing procedures to promptly respond to RAC requests for medical records.
If the provider disagrees with the RAC determination, filing an appeal before the 120-day deadline.
Keeping track of denied claims and correcting these previous errors.
Determining what corrective actions need to be taken to ensure compliance with Medicare’s requirements and to avoid submitting incorrect claims in the future.

CMS will continue to monitor the efforts of the RACs to ensure they are providing sufficient information and undertaking outreach activities to reach all the health care providers in their regions so no provider feels unreasonably burdened.

Fmr. Assistant United States Attorney-Senior Attorney OIG-HHS Kenneth Haber advises all healthcare providers and facilities: the CMS RAC attacks are at the door and so is the National Practitioners Data Bank. Ken is a CMS, RAC, ZPIC Attorney Lawyer.